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The Australian Health Practitioner Regulation Agency (AHPRA) looks forward to contributing to the review of hospital safety and quality assurance in Victoria that was recently commissioned by the Department of Health and Human Services in the light of the tragic deaths of babies at Bacchus Marsh Hospital (Djerriwarrh Health).

Summary:

AHPRA reports on an independent review of how it manages notifications in Victoria

AHPRA welcomes positive trend in reporting by employers and practitioners

‘We want to make sure we play our part as regulators of registered health practitioners in the broader system of safety and quality assurance to help prevent this from ever happening again’, said AHPRA CEO, Mr Martin Fletcher.

‘As regulators, our job is to make sure that any ongoing risk to the public with individual practitioners has been addressed so patients are safer into the future’, said Mr Fletcher.

AHPRA and Boards regulate more than 165,000 individual registered health practitioners in Victoria across 14 professions. AHPRA is now investigating a number of registered health practitioners who practised at Bacchus Marsh Hospital at the time of this tragedy and other matters that have been notified to them.

These investigations involve examining many thousands of pages of clinical records and gathering information to identify the individuals who provided care, and establish what happened and what should have happened in each case. AHPRA has sought expert clinical advice to help analyse this information.

‘We owe it to the families who have suffered terrible loss, and the community, to make sure our work is thorough and fair’, said Mr Fletcher.

‘We are identifying a range of issues, from tragedies that were the result of people doing their best in a flawed system of clinical governance, to individual health practitioners who need to further explain what they did or didn’t do.’

‘This work is continuing and at this time, we can’t provide more detail By law, we can’t publicly identify individuals who are under investigation and talking publicly about numbers and professions in a small health service would necessarily identify individuals. Also, the numbers change as we learn more about what happened, identify who was involved and assess whether they did what they ought to have done. New cases open, other matters close’, said Mr Fletcher.

‘We have updated Djerriwarrh, the Department of Health and Human Services and the Health Services Commissioner on the scope and focus of our investigations, in the public interest. We have updated these other agencies on our work, so they can assure themselves that any systems issues that are outside the scope of what AHPRA has the mandate to investigate are being, or have been, effectively addressed,’ said Mr Fletcher.

Independent review

In 2015, AHPRA commissioned an independent review of the notifications systems and processes in its Victorian office to make sure they are doing all that is needed to address concerns about the length of time it took to manage a notification about a practitioner from the Djerriwarrh Health Service three years ago.

‘Community trust in what we do is very important. We recognise that community confidence in health regulation was damaged by the tragedy at Djerriwarrh’, said Mr Fletcher.

‘We wanted to make sure there were no problems we weren’t already dealing with and confirm that the changes we were already making were on track and would strengthen health practitioner regulation for all Victorians.’

The review was undertaken by KPMG and led by Penny Armytage, Partner, KPMG.

‘We have acted on all the recommendations of the review, which support many of the changes we had already made and others that were already in train when we received the report,’ said Mr Fletcher.

The report recommends actions in five main areas.

Better risk assessment: embed a more systematic, data informed approach to risk-assessing notifications not only taking account of the information which is outlined in the notification, but also factors such as a practitioner’s history of notifications, their practice context and who made the notification.

Management of high risk matters: more intensively apply resources to higher-risk notifications, so these cases are investigated thoroughly but quickly.

Greater transparency: interpret and use the National Law flexibly, not narrowly, to support information-sharing in the public interest and promote greater understanding and transparency of what we do.

Culture: effectively balance the needs and rights of the public, employers and practitioners, and address community perceptions that our work is pro-practitioner.

Performance: continue to critically evaluate and act upon the causes of delays, especially for high risk and complex cases.

Reporting

Under the legislation administered by AHPRA, it is a requirement for registered health practitioners and their employers to notify AHPRA of concerns about individual doctors, midwives and other practitioners.

‘We rely on employers and health practitioners meeting their mandatory reporting obligations and telling us if there is a problem. I urge employers and practitioners to know their obligations, and make sure they meet them’, said Mr Fletcher.

Historically, Victoria has had a lower rate of mandatory notifications when compared to national figures. However, this gap appears to be closing. In 2014/15, the national rate was 9.89% of all notifications received and the Victorian rate was 9.05% for all notifications received for all professions.

‘We welcome this positive trend in mandatory reporting rates in Victoria. While there is variation across professions, it is encouraging to see our work with health services and health practitioners in raising awareness about these obligations taking effect’, said Mr Fletcher.

AHPRA is running an awareness campaign on reporting obligations and will continue its work with the Department, practitioners and the public to ensure concerns are being raised so regulatory action can be taken when this is needed.

Anyone with concerns about a registered health practitioner can make a notification to AHPRA.

Background

Who does what in the Victorian health system?

Regulating individuals: AHPRA and National Boards set the policies and regulate registered health practitioners, including receiving and managing complaints about the health, conduct or performance of practitioners.

Managing health service complaints and mediations: the Health Services Commissioner receives and resolves complaints about health service providers with a view to improving the quality of health services for everybody.

Responsible for the broader health system in Victoria: The Department of Health and Human Services is responsible for supporting service delivery of the health system to meet health needs of Victorians.